Flow velocity waveforms of the uterine artery in pregnancy: transvaginal versus transabdominal approach

Our objective was to compare recordings of flow velocity waveforms from the uterine artery via the transvaginal and transabdominal approach in normal human pregnancies. In a cross-sectional study from 16 to 40 weeks' gestation, 88 healthy pregnant women underwent a continuous-wave Doppler examination of their uterine arteries by both the transvaginal and the transabdominal approach. Measurements were recorded for both uterine arteries and averaged. Values recorded transabdominally were significantly lower than those obtained transvaginally in all patients < or = 27 weeks' gestation. From 28 weeks to term, transabdominal values remained lower, but the difference was smaller and insignificant, and noted only as a trend. Transvaginal velocimetry of the uterine artery produces significantly higher systolic:diastolic ratios than that of transabdominal recordings until 27 weeks' gestation. Thereafter, trophoblastic invasion of the uteroplacental circulation is maximal, and the difference between the values are minimal and insignificant. However, a pattern of lower resistance in the transabdominal approach remains consistent until term.

Fetal pleural effusion: the risk of fetal trisomy

Our objective was to review the association between fetal pleural effusion (FPE) and fetal aneuploidy. We conducted a retrospective survey of pregnant women who presented to our ultrasonographic unit between 1990 and 1991, and in whom the diagnosis of FPE was reached. All fetuses had karyotype investigation and a complete ultrasonographic search for associated anomalies. Six cases of FPE were identified. Trisomy 21 was found in 2 (33%). The English literature was reviewed and an additional 147 cases with FPE were collected, among them 6 cases of trisomy 21 and 1 of monosomy 45X. In this accumulated series the risk of aneuploidy in a fetus with an incidental finding of FPE was 5.8% (9 of 153), thus warranting a karyotype study.

Continuous wave Doppler velocimetry of the main-stem uterine arteries: the transvaginal approach

The purpose of the study was (1) to establish the efficacy of the transvaginal approach for continuous wave Doppler velocimetry of the main-stem uterine arteries in normal pregnancy and (2) to provide reference values for the flow velocity waveform indices of the main-stem uterine arteries in normal pregnancy. In a cross-sectional study from 16 to 40 weeks of pregnancy, 201 healthy normal women were examined by transvaginal continuous wave Doppler, and flow velocity waveforms were obtained from the main branch of the uterine artery on both sides. Nomograms were compiled for the systolic: diastolic ratio, pulsatility index and resistance index. Values for all variables declined during the course of pregnancy until 22 weeks' gestation, and then remained stable to term. Intra- and interobserver variations were 5% and 8%, respectively, and the examination time was < 5 min. Flow velocity waveform indices declined during pregnancy, indicating a decrease of resistance in the uteroplacental circulation. Our results are comparable to those obtained transvaginally by pulsed wave Doppler, previously reported in the literature. The transvaginal approach for continuous wave Doppler velocimetry of the main-stem uterine arteries is a simple, quick, accurate, safe, cheap and highly reproducible method, and is therefore suitable for evaluating the uteroplacental circulation.

Macroglossia: prenatal ultrasonographic diagnosis and proposed management

A case in which macroglossia was the sole unusual prenatal sonographic finding in a fetus affected with trisomy 21 is presented. The differential diagnosis of fetal macroglossia is given, emphasizing its strong relationship to fetal aneuploidy, together with the principles for evaluation and management.

Reversal of fetal distress following intensive treatment of maternal diabetic ketoacidosis

Diabetic ketoacidosis during pregnancy is frequently associated with fetal distress that may result in fetal death in utero. A patient at 33 weeks of pregnancy with diabetic ketoacidosis and evidence of fetal distress is presented. Following intensive medical treatment, maternal metabolic state improved along with improvement of fetal heart rate tracing. A healthy infant was delivered by cesarean section at 36 weeks of gestation.

Transvaginal echocardiographic examination of the fetal heart between 13 and 15 weeks' gestation in a low-risk population

The object of our investigation was to evaluate the potential of transvaginal echocardiography for a complete anatomic study of the fetal heart, and for detection of congenital heart diseases in low-risk pregnant patients between 13 and 15 weeks' gestation. High-frequency (6.5 MHz and 7.5 MHz) transvaginal probes were employed for fetal echocardiographic assessment. Six hundred and sixty patients considered at low risk for congenital heart disease underwent in utero ultrasonographic studies, neonatal records, postnatal imaging studies, and pathologic examination. The four-chamber view was obtained in 100% of the fetuses, while the extended fetal heart examination was completed in 98%. Six fetuses with cardiac defects were diagnosed during the study: three had major heart defects (aortic atresia, tetralogy of Fallot, and persistent truncus arteriosus), all detected at the early transvaginal scan; three cardiac anomalies escaped our early diagnosis; two fetuses had a minor ventricular septal defect diagnosed only postnatally; and one had multiple cardiac rhabdomyoma diagnosed in the third trimester. Our results demonstrate that between 13 and 15 weeks' gestation transvaginal echocardiographic assessment of the fetal heart in the low-risk population is feasible. Moreover, some severe anomalies may be detected at such an early gestational age.

Post-cesarean section febrile morbidity. Antibiotic prophylaxis in low-risk patients

A study was conducted to assess whether antibiotic prophylaxis in low-risk patients for post-cesarean febrile morbidity was beneficial and cost effective. In a randomized, prospective study, 167 patients received a single, 1-g dose of cefazolin before clamping of the cord, and 140 did not. In the group given prophylaxis the febrile morbidity and postoperative therapeutic antibiotic usage were significantly lower than in the group not given prophylaxis (9% vs. 17.9%, P = .035, and 6.5% vs. 20%, P < .001, respectively). We conclude that single-dose cefazolin prophylaxis is both beneficial and cost effective, even in patients considered to be at low risk of post-cesarean febrile morbidity. Since the value of antibiotic prophylaxis in high-risk patients is accepted, universal antibiotic prophylaxis in every cesarean section case is suggested.

Prenatal diagnosis of congenital gastric outlet obstruction

A case of gastric outlet obstruction diagnosed prenatally at 22 weeks' gestation is described. The differential diagnosis and the clinical management of this rare condition are discussed, and an updated literature review is presented.

A prospective randomized clinical trial comparing a new oral sustained-release ritodrine with conventional tablets

OBJECTIVES

Evaluation of maternal metabolic and cardiovascular responses to treatment with the new sustained-release oral ritodrine as compared with the conventional tablets.

METHOD

Thirty-two pregnant patients who had successful intravenous tocolysis were randomly assigned to treatment with either ritodrine tablets or sustained-release capsules. After 5 days of the randomly determined first oral treatment each patient was shifted to the alternate ritodrine formulation for a further 5-day course. Each patient underwent metabolic and non-invasive hemodynamic evaluation.

RESULTS

Echocardiographic parameters during treatment with ritodrine tablets were not significantly different from during sustained-release capsules. Mean systolic blood pressure increased significantly during peak drug activity in patients treated with ritodrine tablets and not during treatment with the sustained-release form. Fasting plasma glucose levels were higher in patients on conventional tablets therapy than in patients on sustained-release ritodrine therapy (88.9 +/- 9 mg/dl vs. 78.7 +/- 8 mg/dl, P < 0.05) while levels following a 50-g oral glucose challenge test did not differ significantly (135 +/- 32 mg/dl vs. 124.5 +/- 27 mg/dl)

CONCLUSIONS

Because of fewer metabolic and cardiovascular side-effects, the new oral therapy offers some advantages over the presently available tablets.

Single fetal demise in twin gestation resulting in the resolution of severe pre-eclampsia

A primigravida presenting with a twin pregnancy and severe pre-eclampsia which developed during early pregnancy is described. Complete resolution of symptoms and signs of pre-eclampsia were evident following the death of a growth-retarded single fetus. Pregnancy continued successfully until 35 weeks of gestation, when a single healthy infant was delivered. Few such cases of complete resolution of pre-eclampsia following the death of a single fetus are reported in the literature. The possibility that genetic susceptibility to pre-eclampsia is conferred by homozygosity for the same single recessive gene expressed by both mother and fetus is discussed.

The first-trimester growth-discordant twin: an ominous prenatal finding

OBJECTIVE

To evaluate the clinical significance and the natural course of discordant twin growth found during the first trimester of pregnancy.

METHODS

This was a retrospective survey between 1992-1993 of women presenting to the ultrasonographic unit with twin pregnancies in which considerable interfetal size variation was noted in the first trimester. Discordant embryonal growth was defined as a difference in crown-rump length corresponding to 5 or more days in the estimated gestational age. Only cases that presented with continued viability of both twins were reviewed. Cases were thoroughly followed by ultrasound examinations throughout pregnancy. Neonatal records provided the outcome data.

RESULTS

Five cases with first-trimester discordant twin growth were identified. All had complications of major congenital anomalies in the smaller twin, ie, diaphragmatic hernia, ventriculomegaly, schizencephaly, critical aortic atresia, and sacral agenesis.

CONCLUSIONS

The first-trimester growth-discordant twin is at increased risk for congenital anomalies. Meticulous sonographic search for congenital anomalies is indicated when inter-twin size variation is evident in the first trimester.

Intravenous albumin for the prevention of severe ovarian hyperstimulation syndrome in an in vitro fertilization program: a prospective, randomized, placebo-controlled study

OBJECTIVE

To evaluate the efficacy of i.v. administration of human albumin solution for the prevention of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A prospective, randomized, placebo-controlled study comparing the effects of i.v. administration of human albumin solution versus sodium chloride 0.9% solution at the time of oocyte retrieval with patients undergoing IVF-ET who are at high risk for the development of severe OHSS.

SETTING

Specialized assisted reproduction unit.

PATIENTS

Thirty-one patients undergoing IVF-ET who had serum E2 levels of 1,906 pg/mL (> 7,000 pmol/L) and multiple follicular development on the day of hCG administration.

INTERVENTIONS

After hCG administration, patients were randomized to receive i.v., either 50 g of human albumin diluted in 500 mL of sodium chloride 0.9% or 500 mL of sodium chloride 0.9% at the time of oocyte retrieval.

MAIN OUTCOME MEASURES

Ovarian size as measured by pelvic ultrasonography, development of ascites, serum E2 concentrations during the luteal phase, and results of the IVF-ET cycles.

RESULTS

Although no patient who had received human albumin solution developed severe OHSS, there were four such cases in the control group. All four were hospitalized with marked ascites and ovarian enlargement. There were no significant differences between the two groups comparing serum E2 levels on the day of hCG administration and during the luteal phase, the number of oocytes retrieved, fertilization, and pregnancy rates.

CONCLUSIONS

Our preliminary results suggest that the administration of human albumin solution may help to prevent the development of severe OHSS in high-risk patients. Further research is needed to assess the potential of this novel approach.

Successful resolution of persistent trophoblastic disease after partial mole with the EMA-CO regimen

A 29-year-old nullipara with partial hydatidiform mole at 8 weeks had pre-evacuation hCG levels of 275,000 mIU/ml. Free beta-hCG levels were measured as 3% (normal value below 4%). The patient developed persistent gestational trophoblastic disease, failed to respond to methotrexate and actinomycin D, but has responded to combination chemotherapy with EMA-CO. Such a response to EMA-CO was not reported previously.

Induction of follicular growth and production of a normal hormonal milieu in spite of using a constant low dose of luteinizing hormone in women with hypogonadotrophic hypogonadism

This study was designed to examine ovarian performance, i.e. follicular growth, normal steroidogenesis and luteal phase function, following the administration of multiple increasing doses of human follicle stimulating hormone (FSH) with a constant low dose of luteinizing hormone (LH) in women with isolated hypogonadotrophic hypogonadism. Human menopausal gonadotrophin (HMG) was used in the first treatment cycle, starting with 150 IU of LH and 150 IU of FSH per day, for 7 days. The dose was increased daily with 75 IU of LH and 75 IU of FSH for another 7 days if no response was detected by serial ultrasound measurements and serum oestradiol determinations. In the second treatment cycle, a constant dose of 75 IU of LH (using HMG) was administered per day and up to 150 IU of FSH (using urofollitrophin) was supplemented. If no response was detected after 7 days of treatment, the dose of FSH was increased. For the final stage of ovulation induction, human chorionic gonadotrophin (HCG) was administered in the presence of at least one follicle > 17 mm in diameter but with no more than three follicles > 16 mm in diameter. To verify the adequacy of the luteal phase, a pharmacokinetic/pharmacodynamic study of beta-HCG, oestradiol and progesterone was performed following the second treatment cycle only. Ovarian stimulation using a constant dose of 75 IU of LH and increasing doses of FSH up to 225 IU, resulted in normal follicular growth and hormonal milieu. Both women showed normal luteal phase oestradiol and progesterone production and both women conceived following the second treatment cycle.

Sonographic measurements of the umbilical cord and vessels during normal pregnancies

Sonographic measurements of the umbilical cord and vessels were performed in 368 uncomplicated pregnancies, and nomograms of their growth were constructed. All measurements were obtained in appropriate for gestational age fetuses in pregnancies with accurate dating. From the above measurements, an estimate of Wharton's jelly quantity (expressed as square millimeters) was calculated. The nomograms presented add another biometric measurement of normally growing fetuses and may serve to differentiate between them and those who are found to have umbilical cord abnormalities.

Declining beta-human chorionic gonadotropin level may provide false security that tubal pregnancy will not rupture

Two patients with declining serum concentrations of beta-human chorionic gonadotropin (beta-hCG) and a ruptured tubal pregnancy with hemoperitoneum are described. Declining beta-hCG does not rule out the possibility that the ectopic pregnancy will rupture.

Neurofibromatosis and pregnancy. An update

Neurofibromatosis is one of the most frequent genetic diseases in humans. Pregnancy in neurofibromatosis patients is, however, less common. Most current information on pregnancy and neurofibromatosis is derived from case reports, which may not reflect the true situation. In the past 15 years only two series of pregnant neurofibromatosis patients were reported in the English-language literature. We present our experience with 34 pregnancies in nine neurofibromatosis patients who delivered at our medical center. While fertility does not seem to be impaired in neurofibromatosis, these patients experience a higher-than-expected rate of first-trimester spontaneous abortions (20.7%), stillbirths (8.7%) and intrauterine growth retardation (13.0%). A high rate of cesarean section (26%) was also observed in our series. We conclude that pregnant neurofibromatosis patients constitute a high-risk group, in danger of developing life-threatening complications. However, with proper antenatal care, most pregnant neurofibromatosis patients can deliver safety if the pregnancy continues beyond the first trimester.

Vaginal delivery of breech-vertex twins

The safety of vaginal birth for breech-vertex twins has not been addressed directly before. We retrospectively compared the perinatal outcome of two groups of breech-vertex twins: 24 delivered vaginally and 35 delivered abdominally. Vaginal delivery was allowed under the same protocol developed for singletons in breech presentation. Both groups had similar maternal and neonatal characteristics except for a significantly higher rate (P = .003) of pregnancies after infertility in the abdominal delivery group. Intergroup differences in perinatal outcome, as measured by Apgar scores and morbidity and mortality cases, were not significant. Our data suggest that if measures for safe vaginal delivery are taken, this route appears to incur no morbidity and mortality for breech-vertex twins.

Evaluation of prognostic factors for vaginal delivery after cesarean section

Although the success rate of vaginal birth after cesarean section in selected patients is > 60%, most of these women elect the option of a planned repeat cesarean section. In this study our purpose was to evaluate the predictive value and relative importance of 15 prognostic factors by using univariate and multivariate analysis in order to refine the selection of patients for a trial of labor. The analyses were based on 261 patients with one prior cesarean section who were allowed a trial of labor. The final model resulted in six significant prognostic factors. The overall predictive value of the model was 68%. However, the predictive value for a successful vaginal delivery was excellent: 94.5% (139/147) of the women predicted to deliver vaginally actually did so. This group constituted 56% (147/261) of our candidates for vaginal delivery. The predictive value of the test for failure was only 33.3% (38/114); 66.6% of the women completed a vaginal delivery despite the prediction of failure. Because the chance of a successful vaginal delivery is > 60% in women with a prediction of failure, until a selection criterion with a better prognostic value can be identified, a liberal approach to vaginal birth after cesarean section is justified even in this group. A 60% chance is perceived by many women and physicians as too low to elect this option. Since we were able to predict a successful vaginal delivery in a large proportion of the candidates, it may encourage at least this group of patients to elect a trial of labor.